Has a physician ever diagnosed you with a heart condition and indicated you should restrict your physical activity?*

Yes

No

Is there a family history of heart disease, high blood pressure or cholesterol?*

Yes

No

When you perform physical activity, do you feel pain in your chest?*

Yes

No

When you were not engaging in physical activity, have you experienced chest pain in the past month?*

Yes

No

Do you ever faint or get dizzy and lose your balance?*

Yes

No

Do you have an injury or orthopedic condition (such as a back, hip, or knee problem) that may worsen due to a change in your physical activity?*

Yes

No

Do you have high blood pressure or a heart condition in which a physician is currently prescribing a medication?*

Yes

No

Are you pregnant?*

Yes

No

Do you have insulin dependent diabetes?*

Yes

No

I acknowledge that the activity I am to undertake is a dangerous activity and that by participating in it I am exposed to certain risks.
I acknowledge and understand that whilst participating in such activity;
• I may be injured, physically or mentally, or may die.
• My personal property may be lost or damaged.
• Other persons participating in such activity may cause me injury or may damage my property.
• I may cause injury to other persons or damage their property
• The conditions in which the activity is conducted may vary without warning.
• I may be injured or die or suffer damage to my property as a result of the negligence or breach of contract of Crossfit KUZA.
• There may be no or inadequate facilities for treatment or transport of me if I am injured.
• I assume the risk of and responsibility for any injury, death or property damage resulting from my participation in the activity.
Release and Indemnity:
I participate in the activity at my sole risk and responsibility.
I release, indemnify and hold harmless Iron Crossfit KUZA, its servants and agents, from and against all and any actions or claims which may be made by me or on my behalf or by other parties for or in respect of or arising out of any injury, loss, damage or death caused to me or my property whether by negligence, breach of contract or in any way whatsoever.
Parental / Guardian Consent:
If I am below eighteen (18) years of age, I shall obtain the written consent of my parent or guardian, whose signature shall be witnessed by member of Crossfit KUZA staff, to be allowed to use the equipment and facilities and participate in the activities.